Select Committee on Health Minutes of Evidence

Examination of witnesses (Questions 80 - 92)



  80. One of the issues that arose there was the way in which resourcing which was primarily for local authority services went in sometimes through National Health Services. Is that something you feel might be helpful? Where we have this problem of working across boundaries do you feel there might be more scope for you as Chief Executive of a trust to influence the process of rehabilitation bearing in mind the point made by you about bed blocking?
  (Mr Pope) I think in my area there has been a great deal of flexibility between health and social care.

  81. There has been?
  (Mr Pope) There has been I think. What we should be focusing on is the outcome, what we are trying to achieve. It does not matter whether it fits into those boxes. I think that is something I have seen particularly this winter where resources have been used between the two areas, bearing in mind the constraints put upon them perhaps within their legal frameworks. There has been a lot more flexibility and I think there is more to come with care trusts etc.

Mr Burns

  82. Could I ask Dr Moffit how much of the brain injury services are in the private sector?
  (Dr Moffit) There is quite a high level of provision in the private or independent sector. It has been mentioned already that there is an enormous range of need amongst people with brain injuries. There is a very large population of people with brain injury who get services almost exclusively from the National Health Service and a very small number who get a service from the private sector. Perhaps you are hinting at the fact that consumes a lot of resource because of the severity of the problem affecting those individuals but in terms of percentage the vast majority of treatments for people with brain injury is within the National Health Service.

  83. Are you able in a very broad way to put a percentage figure on what "vast majority" means? Are you talking about 90 per cent, 95 per cent?
  (Dr Moffit) I would have thought it was 99 per cent. I would have thought it was as high as that. The percentage in the independent sector was incredibly low, or perhaps the percentage of services that should be delivered.
  (Dr Andrews) I think it depends what level of service you are looking at. I think most of the original early treatment of brain injury is on the NHS. If you look at the very specialist services for brain injury, the vast majority is in the independent, either the private or the charitable sector, once you get down to the super specialist type of care.

  84. In the private sector who is paying for that?
  (Dr Andrews) Most of that comes from contracts with NHS authorities.

Dr Brand

  85. Could I ask a follow up. Dr Andrews was nodding his head very vigorously when I asked about OATs and ECRs. Is this something that you would like the Government to address, the funding stream?
  (Dr Andrews) I think one of the problems—and this is something again which I must say the London Specialist Commissioning Group is very concerned about—is the lack of flexibility almost across districts. I think one of the strengths that you can put forward to the Government is that they really need, first of all, for health authorities to have information about how many brain injured people they have got, which they do not generally have, and the levels of disability. They need to have care pathways drawn up and that will include moving out of your own health authority to the most appropriate within your area. In fact, we are all keen that there should be very clear information about what is available, what the waiting times are and how you get into those and really for there to be preferred units to go to from the health authorities. That way you need to move money across districts to be able to enable people to get the best treatment. This is why again I think the specialist commissioning at a region or a multi PCT level is going to be required. That is what OATs is actually doing.

  86. You see the answer being specialist commissioning rather than back to the ECR type arrangement? It was interesting listening to the earlier witnesses where clearly a health authority cannot anticipate (a) how many injuries they will have and (b) cannot always work out whether it is better for those people to be near relatives which may be nowhere near the home district.
  (Dr Andrews) Yes.

  87. It may well be it is in the interests of the patient to be outside the pattern that you are describing. Certainly I am having difficulty with my own patients to achieve that.
  (Dr Andrews) Yes.

  Chairman: On this point about specialist commissioning, obviously we have wrestled with these areas in a number of other specialist areas as well, particularly mental health. Do you have any thoughts on how that structure might be achieved? Are we talking here about some of these specialist units in areas? Are we talking about some common new body that may be called a PCT that would handle this kind of commissioning?

  Dr Brand: Regional Health Authorities.


  88. Exactly.
  (Dr Andrews) I suspect it is going to be dealt with differently in different areas. If you have a very intensive area, such as London, then it is easy to work across districts. If you are in a more rural area it is very much more difficult to get that level of collaboration. This means that you then are having to travel long distances to get the level of care that you require. I would assume in some areas that it should be the old Regional Health Authority type of commissioning that a group of that size takes it on or a group of health authorities or even a group of PCTs. Personally I do not care who does it as long as it is done effectively and at the end of the day the patient gets the best treatment in the most appropriate place.

Mrs Gordon

  89. Could I ask Dr Turner-Stokes and Mr Pope how have you managed to develop a good service for brain injured people in your area given that obviously from the evidence we have had others have not been able to do that? Obviously your own enthusiasm is important but were there other special factors that enabled you to do that? What is stopping other trusts and health authorities from doing the same thing?
  (Dr Turner-Stokes) First of all, I would say we are not perfect and we have still got gaps, but we have gone some way down the route. I think there are three main factors that help. Firstly, there was a sum of funding and that came from the dissolution of ALAC, which was the wheelchair and prosthetic service. Central funding for that was devolved down and in our region due to the foresight of North West Thames Health Authority and the efforts of my colleague, Andrew Frank, that was put together to make a regional service. Secondly, we were specifically instructed in that service not just to be a unit that was self-sufficient and did not talk to anybody else but to be a catalyst for development of services across the region. That was our brief. So the organisation was of the hub and spoke model which I have presented evidence on and also expanded on quite a bit. The idea was not only to be a centre of clinical excellence but also a centre for training and research across the region. That has meant we trained professionals from all disciplines involved in rehabilitation training programmes, so that very often when services are being set up now around the region those are populated by people we have trained. That comes back to it is not just about resourcing but the training and keeping that going. Thirdly there is the enthusiasm. I think I would have to say that there has been tremendous collaboration from all the consultants around us in the region and in the teams, especially my own, who really have worked all hours God gives. That is the crucial thing. It takes a huge amount of effort. One of the things that one cannot really quite emphasise enough is that you need to know that you have got continuity of funding. You need to know it is long term so you can put in the infrastructure that was identified. It takes ten years to develop a team and you have got to know it is not going to be disbanded next month or next year because the contracts are going to change, or we might not get ECRs, or we might have to lose some people. I think that is critical, so specialised commissioning will give the stable funding. Finally there is the support of the Chief Executive. Then it was Mike Cole, John's predecessor, but hopefully now John and his team will be giving support to develop it. Those are the crucial things allowing us to develop the service. I can talk about some of the barriers but I have talked enough.
  (Mr Pope) I do not think there is much to add in some ways. It is back to the issue about when does it become a priority, and sometimes it takes a team that has a vision as to how things can be. The way that works with chief executives is if you have something that is comprehensive, if I had one clinician coming at me, perhaps just a doctor, I would be looking for the therapists, I would be looking for the links to other hospitals, I would be looking for work with primary care and perhaps the voluntary sector. That would make it attractive to me and I am sure that is a bit of how this service came together. Sometimes the inspiration is not there and you need help from groups like this to push something and say this is how it can be. The barriers are clear. There are many, many competing priorities as we are going through a massive amount of change in the service.

John Austin

  90. I am curious about joint commissioning. Leaving aside the complexities of PFI, there will be some capital as well as revenue expenditure on the services. Do they come down a different route and is that a problem for the joint commissioning approach?
  (Dr Andrews) I do not think I am quite with you on the concept here.

  91. The sources of the revenue are different. Does that make a problem in planning comprehensively?
  (Dr Andrews) At the end of the day most things in health care or in any organisation depend on people and if you can get the relationships between two organisations right—and we all know of health and social service departments who have the same office and others who will not speak to each other. That all boils down to people. What is really required is very clear guidelines on who takes responsibility for which element of funding. You can look at a nursing home now and find that one patient is being funded entirely by the health authority, another one with exactly the same problems joint funded, and a third one is being funded purely by social services with all the implications of means testing. There is something wrong if we cannot get very clear guidelines so we can have equity across the country. That is what is required, guidelines of who should take responsibility, at what level and a mechanism whereby people are forced to discuss things. One of the strengths of the PCTs will be this greater relationship with social services as part of that primary care trust.
  (Dr Moffit) There is no doubt that there are some niche services already provided in the independent sector. If specialist commissioning continues to provide funding for patients in the same way as it does at present, and does it more efficiently so that patients arrive in this sector at an earlier stage then the value returned to the funders will be greater because if what you will have delivered is in a more appropriate time and more effective and lasts for a shorter period, the individual can be got back to their home area in a shorter period, to everyone's advantage.

  92. I was going to ask whether the concordat with the private sector has made any difference in this particular area?
  (Dr Moffit) Not evidently, I have to say. The sentiment of it really supports the practice in a sense because the patients who come to the independent sector at the present time are frequently patients whose needs are so overwhelming that they are funded because a service has to be found and there is not another available choice. The concordat does not add to that but, as I understand it, the philosophy of the concordat would be entirely behind it.

  Chairman: Can I thank you for your very helpful evidence this morning. We are most grateful for the help you have given this inquiry. Thank you very much.

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